HERNIAS then (1990) and now (2011)

Steven E. Swartz, MD, FACS

Surgical Associates of Richmond

Objectives

Understand Hernia Types

Understand Where We Are Today Concerning

Repair

Understand Anatomy Associated With Various

Types Of hernia

Understanding the Repairs and What

Documentation needs to be on the report.

What do we tell patients?

Do all hernias need to be repaired?

Should mesh be used?

Open or laparoscopic?

What is a hernia?

Do all hernias need repair?

Inguinal -550.90

Umbilical -553.1

Ventral -553.20

Incisional -553.21

Do all hernias need repair?

1990- Yes, to relieve

symptoms and prevent

complications

2011- No, only those

that are symptomatic or

high risk

Watchful waiting

Inguinal hernias Fitzgibbons et al 720 men with

minimal symptoms

23% had surgery within 2 years

Serious complications were rare in the non-

operated group

Should mesh be used?

+49568 for open ventral/incisional

1990- No, only on multiply recurrent hernias because of the risk of infection

2011- Yes. The infection risk is <5%, most are superficial and do not infect the mesh. The recurrence rate without mesh is 25% for inguinal and 40+% for umbilical/incisional

Are there alternatives?

Unchanged since 1600

Incisional

1990 Repair all

2011 Repair if

symptomatic

Where to place mesh,

what kind of mesh, how

to avoid complications

and recurrences

Inguinal-Laparoscopic or open?

1990-Laparoscopic

General anesthesia

More difficult dissection

Less secure mesh

Higher recurrence rate

Fewer infections

More major complications

Less pain

2011-Open

Local/sedation

Quick/simple

More secure mesh

Fewer recurrences

No major complications

Modest pain-most back to work in 1 week

Incisional hernias

Incisional hernia repair

Reduce hernia, remove sac, replace rectus

Large Incisional Hernia

553.21/552.21

K43.91/K43.01

Hernia sac outlined

Dissect sac from sub Q

Remove sac

Reduce hernia contents

49560

Free posterior rectus fascia

15734 per side, not approved -50 use

-59

Close posterior rectus fascia

Cut mesh to size +49568 or 15430 (bovine pericardium)

Suture mesh over fascia

Close anterior fascia over mesh

Make it pretty

13101/+13102

Complex problems

50 yo woman, prior mesh repair X 2

Chronic infected mesh (MRSA)

Morbidly obese (450 lb, 5’6’’)

Biologic mesh

Human skin, porcine skin or intestinal

submucosa, bovine pericardium

Treated to remove antigenic proteins

Reduced to collagen matrix

Attracts host stem cells which differentiate into

native tissue

Becomes vascularized/replaced

Resists infection

Biologic mesh- Veritas

One year later

Parastomal hernia

Colostomy after abdominoperineal resection for colon cancer, then pancreatic cancer with Whipple procedure and chemoradiation - 990

Parastomal hernia noted on f/u -569.69

Repaired twice in 3 months, still had hernia

Redundant colon

Repair with Veritas

The next generation